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HISTORY

Kraepelin, Alzheimer and Munich

Ramesh Gupta

Objective:

To provide a glimpse of psychiatry’s past, which the authorobtained during a recent sabbatical in Munich.

Conclusions:

An examination of Kraepelin’s memoirs, his first address toMunich’s Ludwig-Maxmilians University and Alzheimer’s notes from pub-lications reveal that the two were dedicated and observant clinicians whocontributed to the scientific foundations of modern psychiatry.

Key words:

Alzheimer, history, Kraepelin, Munich, psychiatry.

he city of Munich takes its name from

Muenchen

, meaning‘monks’. It had been a monastery and, from the 12th century on,was settled as a city. In modern times it has had an infamous

history, being the capital of the Nazi movement, but there is much moreto Munich than that connection. From a psychiatric perspective, myrecent sabbatical took me to the Department of Psychiatry of the city’sLudwig-Maxmilians University. It is an example of Jugenstil architectureand was designed by renowned architect Max Littmann, who alsodesigned the Prinzregenten theatre. Both buildings survived the alliedbombings in World War II.

First morning was a tour of the department, conducted by ProfessorKapfhamer, second in charge. A grand entrance hall with a high ceilingprovides access to various levels and the wards. In the hall were portraitsof past directors of the department. Among them was Emile Kraepelin,who established the concept of dementia paraeox, later consolidated byBleuler under the rubric of schizophrenias.

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The hospital wards areseparated by large, open courtyards that to this day have tall treesplanted by Kraepelin himself. Some of these he brought from his travelsin the east. The courtyards provide venues for relaxation and sportingactivities.

Readers would be interested to learn that Alois Alzheimer also worked atthe university. A remark in Kraepelin’s memoirs reads: ‘It was only afterAlzheimer had failed in his ambition to become director of an institutionthat he came to me and I succeeded in persuading him to join our group.Before he could be appointed to a university post in Heidelberg, I wasoffered the chair in Munich and he moved there with me in 1903’.Kraepelin’s ideal, a natural system of nosology with prognostic implica-tions, encouraged Alzheimer to devote himself to theoretical questionsand the task of bringing together histopathological and psychopatholog-ical findings and models.

Alzheimer’s classic paper on a strange and severe illness of cerebral cortexoriginates from a case report of a 51-year-old woman from Frankfurt,whose symptoms included disorientation, aphasia, delusions and unpre-dictable behaviour, and who died in April 1906 after 4

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Pathological examination revealed diffuse atrophy of the entirebrain and characteristic changes in its internal structure, in particularthe cortical cell clusters. The findings were presented at a Congress inTübingen in 1906. In 1911 Alzheimer seemed surprised when he statedthat Kraepelin in the eighth edition of his psychiatric textbook hadalready given a short summary of presenile dementia with diffuseatrophy of the brain and called it ‘Alzheimer’s disease’. Among many

Ramesh Gupta

Consultant Psychiatrist, ACT Mental Health Service, Phillip Health Centre, Woden, ACT, Australia.

Correspondence

: Dr Ramesh K. Gupta, ACT Mental Health Service, Phillip Health Centre, Woden, ACT 2606, Australia. Email: ramesh.gupta@act.gov.au

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publications and archives of the time, it was fascinat-ing to find Alzheimer’s vocal opposition to theproposal for induced abortion in mentally illwomen.

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He rejected any overly simplistic socialDarwinism, which postulated that the process ofdegeneration is intensified in the offspring of men-tally ill patients.

Kraepelin emphasized commitment to duty andteaching, but with a sense of humour. The followingextract from the Kraepelin memoirs illustrate this.

In 1892, I tried to clarify whether the use of alcoholwas practical for mental health reasons. To my sur-prise, I found that there was really no reasonablemotive for drinking unless one wanted to improveone’s mood. This discovery impressed me. Until now,I had considered the use – even the necessity – ofalcohol to be undisputable. Therefore, I thought thatone had to put up with the dangers of alcohol, whichwere only too well known in my career. At this time,I met Forel again, as I had been requested by the gov-ernment of the Canton Freiburg in Switzerland to givemy opinions on the establishment of a psychiatricclinic in Freiburg. On this occasion, there was muchtalk about the problems of alcohol. I slowly becameconvinced that I should use my own personal absti-nence to fight against the usual drinking customs andthe serious problem of alcoholism in our country.Therefore, I did not drink one drop of spirits for somemonths and during a journey to Madeira in 1894,I turned down the wines, which were offered to mepersistently. I stopped drinking wine and beer onsocial occasions. At first, I was considered to be acrone. A campaign was launched against me withgood and bad jokes, people picked quarrels with me ortried to give me good advice. The worst problem wasthat I was constantly involved in endless discussionson alcohol. My strange views were gradually acceptedand an increasing number of people assured me thatI was quite right and that they hardly drank either,only now and again on social occasions. I caused asensation. I am quite sure that my entire scientificwork did not make my name as famous as the plainfact that I did not drink alcohol.

On the third floor of the university was the labora-tory in which Alzheimer spent many years – withoutpayment from the university because he had inher-ited a fortune – and that now serves as a museum.The original microscopes are still here. There is alsorecord that Creutzfeldt and Jakob were among theproteges who assisted Kraepelin and Alzheimer in thedepartment.

While Kraepelin set the platform for devotion toclinical excellence, it is Alzheimer’s name that isarguably more synonymous with scholarship in thisdepartment. Alzheimer commented critically on theway clinical information was obtained in psychiatry,stating ‘what we urgently need in the field of mentaldisorder is an improvement in the way symptoms arerecorded. Today, to their detriment in my opinion,case notes are often more a summary or judgement

than a description of original complaints and symp-toms by the patient.’

Alzheimer had a profound influence on modernpsychiatry in the way he supported Kraepelin’snosological concepts against those of Hoche. Alz-heimer maintained that the unsatisfactory distinc-tions between various psychiatric conditions could beresolved through progress towards psychiatry thatwas orientated towards the ideals of natural scienceand was not, as Hoche claimed, simply an inevitableconsequence of an uncritical ‘hunt for phantoms’(i.e. natural categories of disease). Like many psychi-atrists before him, Alzheimer regarded the history ofthe investigation of general paralysis as a paradigmfor the success of the research method to which headhered. He appeared to have felt more at home inthe difficult terrain of nosology than Kraepelin, whowas frequently plagued by doubt. In an essay of 1910,Alzheimer describes clearly the distinction between‘organic’ (or ‘exogenous’) psychoses and ‘functional’(or ‘endogenous psychosis’). He classifies dementiapraecox as belonging to the first group ‘on account ofhistological findings and … its tendency to result ina state of idiocy or dementia’; into the second grouphe puts ‘manic-depressive psychosis, paranoia, hys-teria litigious paranoia and degenerative psychosis inthe narrow sense’.

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Alzheimer later moderated hisstance on the dichotomy to take Bleuler’s positioninto account from the latter’s compelling monographon the schizophrenias. However, the undertones ofAlzheimer’s disappointment are evident when hecalled the available data on histopathology, ‘ratherinsufficient’ (i.e. not convincing enough to supportBleuler’s hypotheses).

Alzheimer left Munich in 1912 to take up the profes-sorial Chair of Psychiatry at the University of Breslau.On the train journey to Breslau he contracted puru-lent tonsillitis and subsequently developed subacutebacterial endocarditis. Kraepelin recalls his last meet-ing with Alzheimer thus.

I saw him in Breslau in 1913 at the meeting of Germanpsychiatrists … he was in low spirits and despondent,he had gloomy misgivings about the future. In hisefforts to carry out his duties as well as possible,Alzheimer neglected to take care of himself, as theever more difficult conditions of wartime forced himto take on one new responsibility after another.

He died on 19 December 1915 at the age of 51.Uraemia is the cause of his death given by mostsources.

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Alzheimer had intended to produce empirical evi-dence in favour of Kraepelin’s nosology, especially forthe dichotomy between dementia praecox and manicdepressive illness by means of histopathology. How-ever, he did not succeed in that endeavour and itis fair to say that any significant histopathologicalfindings in dementia praecox still elude us. Alzheimer

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favoured a ‘medical’, in modern terms a ‘biological’,approach to psychiatric research and emphasizedthat research should be firmly related to clinicalquestions.

Almost 100 years after Kraepelin and Alzheimer, thesame third floor of the university now houses alarge and highly sophisticated laboratory. The staffare dedicated to research in molecular pharmaco-genetics and psychoneuroendocrinology. Drugeffects on genes of the signal transduction path-ways, association studies concerning treatmentresponse and incidence of side-effects with geneticvariants of candidate genes, functional genetics and‘proteomics’ (i.e. the identification of new genes andproteins that are involved in the pathophysiology ofpsychiatric disorders) are now being studied. Severalhundred patients and their family pedigrees providea large pool of data. Previous director Hans Hippius

and the current director Hans-Jürgen Möller havebeen major forces in the world of biological psychia-try and psychopharmacology.

ACKNOWLEDGEMENTS

Everyone I met in the university was very kind and most helpful. I particularly thankProfessor Hans-Jürgen Möller for his help and guidance. I also thank ProfessorKopfhamer and Dr Köpf for their encouragement during my sabbatical.

REFERENCES

1. Mayer-Gross W.

Clinical Psychiatry

. London: Roth, Bailliere, Tindall and Cassell,1960.

2. Alzheimer A. Über einen eigenartigen schweren Erkrankungsprozess der Hirnrinde.

Allgemeine Zeitschrift für Psychiatrich Psychologie Gerichtlich Medizin

1907;

64

:146–148.

3. Alzheimer A. Ueber die Indikation für eine künstliche Schwangerschaftsunter-brechung bei Geisteskranken.

Munchener Medizinische Wochenschrift

1970;

54

:1617–1621.

4. Hippius H, ed.

Memoirs by Emil Kraepelin

. Berlin: Springer, 1987.